Paul Lucas, MD, FACS, RPVI, a Vascular Surgeon and Division Chief at Mercy Medical Center, Baltimore talks about Chronic Mesenteric Ischemia, how it hides, and how it is treated.
Interview conducted by Ivanhoe Broadcast News in December 2018.
I wanted to ask you a little bit about Mesenteric ischemia, what is it and what else has it been called, is there something else people might be familiar with?
Dr. Lucas: People look at the peripheral arteries disease as a disorder of a singular term. It really encompasses a lot of things. It could be coronary artery disease, it could be peripheral artery disease in your legs, could involve atherosclerosis or narrowing in your mesenteric arteries which are the arteries to our gut for lack of a better word. But Mesenteric ischemia in and of itself is a condition of a deficiency or a lack of blood flow to the arteries of the intestines caused by usually a buildup of plaque or atherosclerosis.
When you have this buildup in the artery what are the symptoms?
Dr. Lucas: That’s a great question. Usually it presents with vague abdominal pain which is a very typical presentation, people with some GI upset end up going to their primary care doctor and going through an extensive workup. It could involve a gastroenterologist. Ultimately it could lead to an endoscopy where you look with a camera down in to the stomach and then from there it could lead to an ultrasound to actually look at the vessels. It’s a relatively uncommon condition effecting less than two hundred thousand people in the United States annually. It’s not very common overall.
What causes it?
Dr. Lucas: It’s caused by a buildup of plaque in the arteries that lead to the gut. And if left untreated could lead to a condition called acute Mesenteric ischemia which can be a life threatening emergency as it can lead to bowel perforation, infection and things like that.
Is it genetic, are some people more predisposed to having it?
Dr. Lucas: the condition is not genetic in of itself; however some people have a genetic propensity to the development of atherosclerotic disease, and others may have compression of the vessel by a ligament The condition is more common in women. It usually presents in people over the age of fifty, diabetics, hypertensive patients and smokers.
You mentioned a vague stomach issue would be the first thing, are there other symptoms they should watch for?
Dr. Lucas: Yes, one in particular with this entity is weight loss. People will tend to not only lose weight but they’ll develop overtime what we call a food fear. Some people will decrease their intake of food for fear that they will develop abdominal pain which can typically present within fifteen minutes to an hour after eating. And then once it presents, it can stay with them for up to ninety minutes or so.
What are the treatments, and are there different levels depending on how severe the case is?
Dr: Lucas: Yes, after ruling out the other etiologies, a mesenteric duplex ultrasound is performed. This is an ultrasound done with a probe on the abdominal wall. We can look at the arterial anatomy and the flow within those vessels. So when we have the criteria that meet the diagnosis of a significant or severe stenosis or narrowing of those arteries, the superior mesenteric and the celiac arteries. Usually one of those two or both of them could be involved in this entity. Then there’s a couple treatments, the traditional treatment was an open abdominal surgery, with a bypass of those stenotic problematic vessels. More recently, there are minimally invasive approaches that we tend to use more often now, which would involve an angiogram just placing a catheter in the artery, and using IV contrast dye to delineate the anatomy and show the narrowing. We can then treat it with balloon angioplasty and stents to improve the caliber the vessel, and thus improve blood flow.
So much like our viewers might of heard how you open the vessel in the heart with a stent, is it similar procedure?
Dr. Lucas: Exactly
Could you explain that for me?
Dr. Lucas: So, what happens is we access the femoral artery in the groin or sometimes we go from the radial artery in the arm, place a wire down into the abdominal aorta at the level of the take off those mesenteric vessels and then over that we place a sheath and the catheter. Through a catheter we’re able to inject the contrast to show that anatomy and then we can access with special catheters with different angles on the catheters to be able to get in to those vessels themselves with a wire followed by the catheter and then really delineate it very accurately. Then intervention can be rendered within a specific vessel and site of the problem.
Can you treat most patients this way now, or is it fifty/fifty with a larger surgery required?
Dr. Lucas: That’s a great question. Most of the time we can treat these minimally invasively…
And what’s the recovery like, what are the symptoms after the procedure?
Dr. Lucas: The recovery from the procedure itself is really related to the arterial access. So there may be some discomfort in the access site in either the groin or the wrist for several days. Once that’s settles down usually people do pretty well. The abdominal pain in and of itself can take several days to a couple of weeks to really resolve. But usually people will feel some relief very quickly.
And do they have any food restrictions are they able to go back to normal?
Dr. Lucas: No, they can go back to their regular diet. So long as they can tolerate it.
Can you tell me a little bit about Angela? Her case with things she was going through she had a very difficult time with diagnosis, she was telling me.
Dr. Lucas: She did, she did. Number one she is a wonderful, wonderful lady and I very much enjoyed working with her thorugh all of this. She had chronic vague upper abdominal what we call epigastric pain which was really bothersome to her, she had a hard time finding relief. She has been worked up with these other various entities that we have discussed. She’s been at her primary care doctor had some G.I. (Gastroenterologic) workup and ultimately had an ultrasound done which did show a pretty tight narrowing in the superior mesenteric artery.
And from there what was the procedure for her? Were you able to approach it minimally evasive?
Dr. Lucas: I did. She had been treated a couple of times up to this point. The first time I was able to access it from the femoral artery and was able to treat the mesenteric narrowing with a stent.
And then after that?
Dr. Lucas: She did very well initially. And after several months she developed a recurrent abdominal pain. And this is something that can occur in some patients and what she ended up having was an early recurrent narrowing. And when that happens, that’s usually due to an entity called intimal hyperplasia. So for every action there is a reaction. If we put a foreign body into a vessel that the purpose is to have that vessel stay open but the lining of those vessels has what we call endothelium and within that endothelium are smooth muscle cells which can proliferate in response to injury. And that can actually form an early narrowing.
I wanted to ask you since this can masquerade as a couple of different things could you first of all name off some of the other conditions. You said just a general upset stomach. What are some of the things that patients and doctors wind up having to rule out before coming to you?
Dr. Lucas: Because it’s in the central portion of the abdomen, you would need to look at issues with the stomach which could be ulcers, bleeding, things like that, and gastroesophageal reflux (GERD). You also need to look at the liver and the pancreas which are both nearby, and you rule out those issues as well.
So you can have a lot of stuff going on there before you finally rule it out.
Dr. Lucas: Absolutely or it could be an issue with the intestines itself.
Is there anything that I didn’t ask you doctor about this condition that you want to make sure that patients know?
Dr. Lucas: I think it’s really important that we know our body and we listen to the signs that are body tries to tell us, regardless of what it is. If it’s something that’s abnormal, something that’s different, something that you’re not sure of, but it’s not something that should be there and not your norm, it is important to go get it checked out. It may be nothing but if it is something you can have earlier intervention which can lead to a better, healthier outcome.
Of those two hundred thousand cases a year, annually in the United States about how many do you deal with Dr. Lucas?
Dr. Lucas: Personally I would say I deal with between half a dozen and a dozen of these types of cases annually.
But still enough, where it’s in the back of your mind and this might be something I have to add to what I have.
Dr. Lucas: Absolutely. And in a condition that’s relatively uncommon for the most part, as a vascular surgeon we tend to see these issues with some frequency.
END OF INTERVIEW
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